PATIENT INFORMATION - GARLAND PEDIATRIC PRACTICE

PATIENT INFORMATION - GARLAND PEDIATRIC PRACTICE
Last Name
Date of Birth: Race:American Indian/Native AlaskanAsianBlack/African American Email Address:

Apt#City: Sex:MaleFemale Home / Cell Phone: Hispanic /Latino

Native Hawaiian /Pacific IslanderWhiteOther
Pharmacy Name
Insurance Plan
How did you hear about us
CONSENT FOR TREATMENT OF MINOR CHILD

the parent do hereby consent to any diagnosis or treatment rendered under the general or specific instructions of physicians at Garland Pediatric Practice. This consent is given in advance of any specific diagnosis or treatment being required, and it is given to encourage those persons who other than myself bring my child, and said physician(s), to exercise their best judgment as to the requirements of such diagnosis or medical treatment. This consent shall remain effective until revoked in writing and delivered to said physician or to said persons entrusted with the custody, care and control of said minor child.
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ACKNOWLEDGEMENT OF NOTICE OF PRIVACY PRACTICES
Our Notice of Privacy Practices provides information about how we may use and disclose protected health information about you. We are required by law to maintain the privacy of your health information and make every effort to inform you of your rights. The Notice contains a section describing your rights underthe law related to your personal health information. You have a right to review our Notice of Privacy Practices before signing this consent. By signing below,I acknowledge that I have reviewed or had explained to me Garland Pediatric Practice Notice of Privacy Practices and agree to continue my care under said terms.
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INSURANCE AUTHORIZATION AND FINANCIAL RESPONSIBILITY DISCLOSURE
My signature below authorizes Garland Pediatric Practice to release any medical information necessary to process my or my dependent's insurance claim. I authorize any benefits due be paid directly to Garland Pediatric Practice. Your insurance company only provides our office an "estimate" of covered benefits prior to receiving any services or materials from us. This "estimate" is not a guarantee of benefits. I understand that I may be required to pay a deductible, co-pay, co-insurance, or any balance not covered by my insurance plan. If my insurance does not fully pay for services and/or materials rendered to me, I agree to be responsible for payment of all balances on my or my dependent's behalf. | understand that all fees for professional services shall be paid at time of service and are NON-REFUNDABLE. I certify that I have read and understand the above information to the best of my knowledge.
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Insurance Plan
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6448 Broadway Blvd, Garland, Tx - 75043 Phone:(972) 216-8500 Fax:(972) 216-8521

Authorization to Release Medical Records
Patient Name
Patients Date of Birth

MonthDayYear
Date
Parents Name
Cell Phone
Address
I
hereby authorize Garland Pediatric Practice to obtain

Entire Record Immunization Record
From doctor Clinic
Phone
Fax
Address
I understand that this authorization may include information relating to: Acquired Immunodeficiency Syndrome (AIDS) or Human Immunodeficiency Syndrome (HIV) infection, Psychiatric Care, Behavioral or mental health services, treatment for alcohol and /or drug abuse and Genetic Testing.

This authorization will expire onor 90 days from the date set forth below. In accordance with the procedures set forth in the Practice's Notice of Privacy Practices, when information is used or disclosed pursuant to this authorization, it may be subject to re-disclosure by the recipient and may no longer be protected by the federal HIPAA Privacy Rule. I have the right to revoke this authorization in writing except to the extent that the practice listed above has acted in reliance upon this authorization. My written revocation must be submitted in the practice above.
This authorization will expire on
Signature of Parent/Legal Guardian
Relationship
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Purpose of disclosure
TEXAS
Texas Department of State Health Services

IMMUNIZATION REGISTRY (ImmTrac2) Minor Consent Form
Childs First Name
Childs Middle Name
*Children younger than 18 years old only.
Childs Address
Apartment
Email address
example@example.com
City
State
Zip Code
County
Mothers First Name
Mothers Maiden Name
Race (select all that apply): Black or African American American Indian or Alaskan NativeAsian Native Hawaiian or Other Pacific IslanderOther RaceNot Hispanic or Latino Recipient Refused The Texas Immunization Registry (ImmTrac2) is a free service of the Texas Department of State Health Services (DSHS The immunization registry is a secure and confidential service that consolidates and stores your child's (younger than 18 years of age) immunization records. With

Ethnicity (select only one): Hispanic or Latino

your consent, your child's immunization information will be included in ImmTrac2. Doctors, public health departments, schools, and other authorized professionals can access your child's immunization history to ensure that important vaccines are not missed. The Texas Department of State Health Services encourages your voluntary participation in the Texas immunization registry. Consent for Registration of Child and Release of Immunization Records to Authorized Entities I understand that, by granting the consent below, I am authorizing release of the child's immunization information to DSHS and I further understand that DSHS will include this information in the state's central immunization registry ("ImmTrac2" Once in ImmTrac2, the child's immunization information may by law be accessed by: a public health district or local health department, for public health purposes within their areas of jurisdiction; a physician, or other health-care provider legally authorized to administer vaccines, for treating the child as a patient; a state agency having legal custody of the child; a Texas school or child-care facility in which the child is enrolled; a payor, currently authorized by the Texas Department of Insurance to operate in Texas, regarding coverage for the child. I understand that I may withdraw this consent to include information on my child in the ImmTrac2 Registry and my consent to release information from the Registry at any time by written communication to the Texas Department of State Health Services, ImmTrac Group - MC 1946, P. O. Box 149347, Austin, Texas 78714-9347. By my signature below, I GRANT consent for registration. I wish to INCLUDE my child's information in the Texas immunization registry.

Parent, legal guardian, or managing conservator:
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Privacy Notification: With few exceptions, you have the right to request and be informed about information that the State of Texas collects about you. You are entitled to receive and review the information upon request. You also have the right to ask the state agency to correct any information that is determined to be incorrect. See http://www.dsbs.tecas.gov for more information on Privacy Notification. (Reference: Government Code, Section 552.021, 552.023, 559.003, and 559.004) Upon completion, please fax or mail form to the DSHS ImmTrac2 Group or a registered Health-care provider. Questions?wwwImmTrac.comImmTrac DC (512) 776-7284Fax: (866) 624-0180 (800) 252-9152 Texas Department of State Health ServicesImmTrac2 Group - MC 1946Austin, TX 78714-9347 PROVIDERS REGISTERED WITH ImmTrac2 Please enter client information in ImmTrac2 and affirm that consent has been granted. DO NOT fax to ImmTrac2. Retain this form in your client's record. Revised 02/2021
Garland Pediatric Practice Financial Policy

Please read each statement carefully

Please initial each item below, sign and date at the bottom to acknowledge that you have read and understand the office policies and procedures related to the responsibilities of the patient.
me.

If the office is not filing an insurance claim for me, full payment is due at the time of service unless prior arrangements have been approved through the billing department.It is my responsibility to present my insurance card to the receptionist at every visit, even if I believe there have been no changes to my plan.The office will bill my insurance carrier for all covered services if I am covered by a plan that Garland Pediatric Practice is contracted with as a participating provider. I am required to pay all co-payments at the time of my visit.If I do not present my updated insurance card, or give an incorrect insurance card and the claim is denied by the insurance, I will be responsible for any outstanding balance. Garland Pediatric Practice will not re-file the claim forShould my insurance deny a claim due to diagnoses or coding, the office will not change the initial diagnosis or coding just SO my insurance will pay. It is my responsibility to know my benefits and to inform the doctor of such at the time of my visit to best guarantee payment from my insurance.I understand that I am financially responsible for any covered or non-covered services as defined by my Insurer which are not paid by my primary insurance.If no payment is made on my account after four months, my account will be forwarded to a COLLECTION AGENCY and credit bureau for further action. At this time, I will be notified by mail with a 30-day notice of the discontinuation of care. Prompt payment on my account will avoid this action.It is my responsibility to keep all of my information updated with the office such as addresses, phone numbers and responsible party information where statements should be sent.When there is a dispute between parents as to who will be responsible for payment, Garland Pediatric Practice will bill the parent that brought the child to their appointment.If you receive a Nebulizer machine or Aero-Chamber, this is a completely separate billing entity through an outside vendor. Garland Pediatric Practice is not responsible for statements I receive regarding these items.
Please sign below to indicate you have read, understood, and agreed to all of the above financial policies.
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PATIENT INFORMATION - GARLAND PEDIATRIC PRACTICE

ACKNOWLEDGEMENT OF NOTICE OF PRIVACY PRACTICES

INSURANCE AUTHORIZATION AND FINANCIAL RESPONSIBILITY DISCLOSURE

TEXAS